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Dane County Shoreland Zoning Zoning office use only <br /> Permit Application Shoreland Permit#:DCPSHL- <br /> Application must be made in person Zoning Permit#DCPZP- - <br /> Shoreland Zoning Permit fee is$150 <br /> A shoreland zoning Permit will be required prior to a general zoning permit being issued by the Dane County <br /> Zoning Division for any development within the shoreland district. <br /> Property Owner Information /� <br /> Name Agent Nan Nc S `I // <br /> Address ���� � Agent Add 1Vf���9P.( ._.. 0 <br /> X4'7 ;4 5 ?"-' <br /> City State,Zip City,State,_ <br /> r/ -€.-C-eo,i.e- 6-35-2-7 <br /> Pone Agent Phoi <br /> hoe 2-7, 5 - 7-2-0 � <br /> -Mail Agent E-ms <br /> Property/Location Information (http://accessdane.c <br /> Property Address Town/Section c <br /> x-44 P_d eve <br /> Parcel Number(s) <br /> 07//-o1) - /Jo- rj h )r �C <br /> CSM Lot Subdivision Block/Lot <br /> 65 6.7 <br /> Project Description <br /> Please answer the following questions to the best of your ability: <br /> Is the property within 300 feet of a stream or 1000 feet from a pond or lake? g Yes ❑No ❑ Don't Know <br /> Is there a wetland or floodplain on or near the property? ❑ Yes No ❑ Don't Know <br /> Is this project associated with a recent rezone/CUP/variance?ylNo J�, petition/appeal# <br /> Is this permit to correct a violation? ❑ Yes No <br /> Have you contacted the Dane County Land and Water Resources Department about this project? ❑ Yes ❑No <br /> Most applications must be accompanied by a survey showing the following: <br /> ❑ Property lines with dimensions <br /> ❑ All existing structures Permit Fee due at time of application <br /> ❑ Any proposed structures Please have cash or check payment available <br /> ❑ All impervious surfaces at time of application submittal. Checks are <br /> ❑ All vegetative areas payable to Dane County Zoning. The fee for <br /> ❑ Ordinary High Water Mark a shoreland zoning permit is $150.00 and is <br /> ❑ Topographic data(2-foot contours) non-refundable. <br /> I,the undersigned, hereby make application for a shoreland zoning permit and certify to the accuracy of the information. I <br /> further certify I am the property owner,or a duly authorized representative, and may sign this permit application on the <br /> behalf of the owner(s)of said property. <br /> Applicant si nature:' Date: z>9 <br /> pp 9 <br /> H:\Zonine\Shoreland-Wetland Zonine\Chanter 11 Forms\DCPSHL Annlication.docx Version 1.1 Created 12272013 <br />